Provider Demographics
NPI:1437557287
Name:PHILLIPS, SHELLY (FNP-BC)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:658 NORTHSIDE DR E
Mailing Address - Street 2:SUITE A
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-4828
Mailing Address - Country:US
Mailing Address - Phone:912-764-9684
Mailing Address - Fax:912-489-3666
Practice Address - Street 1:658 NORTHSIDE DR E
Practice Address - Street 2:SUITE A
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-4828
Practice Address - Country:US
Practice Address - Phone:912-764-9684
Practice Address - Fax:912-489-3666
Is Sole Proprietor?:No
Enumeration Date:2014-12-10
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA183668363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA14370OtherPROTOCOL NUMBER